Nunatsiaq News
COMMENTARY: Around the Arctic April 09, 2018 - 8:00 am

More than one in 100 Nunavut infants have tuberculosis

"Nobody fully knows the extent of the outbreak."

SPECIAL TO NUNATSIAQ NEWS
From left, Dr. Mike Patterson, Nunavut Health Minister Pat Angnakak, Nunavut Premier Paul Quassa and executive secretary Kailey Arreak help launch a major tuberculosis prevention clinic in Qikiqtarjuaq Feb. 9. A team of TB specialists and health care staff visited Qikiqtarjuaq to screen residents of the Baffin community, believed to have the highest incidence of the infection in Nunavut. As of Feb. 14, 144 people had been screened. Information obtained through an access to information request suggests that the recent tuberculosis outbreak may be much worse than first suspected and that the Government of Nunavut may not have a proper database for tracking contacts. (PHOTO COURTESY OF GN)
From left, Dr. Mike Patterson, Nunavut Health Minister Pat Angnakak, Nunavut Premier Paul Quassa and executive secretary Kailey Arreak help launch a major tuberculosis prevention clinic in Qikiqtarjuaq Feb. 9. A team of TB specialists and health care staff visited Qikiqtarjuaq to screen residents of the Baffin community, believed to have the highest incidence of the infection in Nunavut. As of Feb. 14, 144 people had been screened. Information obtained through an access to information request suggests that the recent tuberculosis outbreak may be much worse than first suspected and that the Government of Nunavut may not have a proper database for tracking contacts. (PHOTO COURTESY OF GN)
Indigenous Services Minister Jane Philpott, at a March 23 press conference in Ottawa, promises the federal government will eliminate tuberculosis from Inuit Nunangat by 2030. She's flanked by Inuit Tapiriit Kanatami President Natan Obed, who worked with the federal government on the issue through the Inuit-Crown Partnership Committee. A report obtained through an access to information request suggests that the tuberculosis in Nunavut, especially among infants, may be much worse than previously suspected. (PHOTO BY SARAH ROGERS)
Indigenous Services Minister Jane Philpott, at a March 23 press conference in Ottawa, promises the federal government will eliminate tuberculosis from Inuit Nunangat by 2030. She's flanked by Inuit Tapiriit Kanatami President Natan Obed, who worked with the federal government on the issue through the Inuit-Crown Partnership Committee. A report obtained through an access to information request suggests that the tuberculosis in Nunavut, especially among infants, may be much worse than previously suspected. (PHOTO BY SARAH ROGERS)

SARAH GILES
University of Ottawa

Canada’s simmering tuberculosis outbreak in northern communities is likely much worse than suspected.

A report newly obtained through an access-to-information request (embedded below) reveals that the incidence rate of TB among Nunavut’s infants—under one year of age—was 1,020 cases per 100,000 people in 2017—a shockingly high level.

In the rest of Canada, the rate is just three infants per 100,000.

Worse, the actual rate may be higher than the report indicates, as it drew only on data from the first nine months of 2017. An additional 21 cases of TB (in people of unknown ages) were identified before the year ended. Many important data points were never collected.

Despite these concerning numbers, the federal minister, Ginette Petipas Taylor, Indigenous Services Minister Jane Philpott and Natan Obed, the president of Inuit Tapiriit Kanatami, recently announced the ambitious goal of eliminating TB from Inuit Nunangat by 2030.

While it is commendable to see political will and $27.5 million over five years supporting TB elimination, similar announcements for TB reduction were made by federal ministers of health in 1997 and 2006. These targets were not met.

The main hope arising from the latest plan is that ITK, the representative organization advancing the rights and interests of Inuit in Canada, is leading the process for the first time.

Hard to diagnose in babies

I work as a family and emergency room doctor in the Northwest Territories. I also have a diploma in tropical medicine and hygiene and I do work with Doctors without Borders.

I have seen the devastation that TB reaps. I am concerned by the high incidence rate of TB in Nunavut’s babies. The poor data we have indicate that TB is a bigger problem than the current numbers reveal.

Eliminating TB in the North in just 12 years may be harder than many imagine.

While most people think of TB as a bacterial disease of the lungs found in resource-poor countries, it can also present virtually anywhere in the body, especially in infants.

TB is particularly hard to diagnose in babies because the symptoms — of poor weight gain, lack of playfulness and fever — are not very specific.

In general, only affluent countries with excellent health care can definitely diagnose babies through technical and expensive tests and, even then, many cases are missed.

It is difficult to know the true extent of tuberculosis in babies throughout the world, but it is patently unacceptable for one in 100 babies in Nunavut to have active TB.

A legacy of fear and stigma

Tuberculosis has been present in the area now known as Nunavut for more than 100 years but it has not always been so prevalent. As recently as 1997, the incidence was 31 cases per 100,000.

TB has once again become an everyday reality for the people of Nunavut—due to the Public Health Agency of Canada’s premature closure of TB control programs like the Canadian Tuberculosis Committee and its Aboriginal Scientific Tuberculosis Subcommittee in 2011, the dramatic under-funding of Indigenous health care, poor social determinants of health and a lack of human resources in the health-care field.

The historical context of the treatment of Inuit with suspected TB cannot be understated. During the 1940s through the 1960s, thousands of Inuit thought to have TB were taken from their villages and sent to sanitoriums in places like Hamilton, Ont.

Most never had a chance to say goodbye to their families and many never returned.

A legacy of fear and the stigma of a communicable disease in small communities continues to deter people from seeking medical help today.

Lifelong cognitive impairment

A person exposed to Mycobacterium tuberculosis bacteria will usually not develop the disease. Some, however, will only partially fight off infection and will develop latent TB. Of those with latent TB, five to 10 per cent will go on to develop symptoms of the disease, or active TB.

Those with weakened immune systems and babies are at heightened risk of developing active TB.

Active TB is a potentially deadly infection and, if in the lungs, is contagious. People exposed to the disease can receive preventative treatment to decrease their risk of developing it.

Though infants in Nunavut receive a TB vaccine at birth, it is not entirely protective.

The high incidence rate of TB among Nunavut’s infants is especially worrisome given that Nunavut has the highest fertility rate in the country, with women giving birth to an average of 2.9 children, compared to the Canadian average of 1.6 children.

This means many more infants are in danger.

While Nunavut did not report any infant deaths in 2017, the consequences of even a successfully treated TB infection can include a host of problems, including lifelong cognitive impairment.

Since babies exposed to TB tend to develop active disease faster than adults, infant TB is a sign that the disease is circulating in the community.

The true crux of Nunavut’s TB problem, as shown by the documents I obtained through the Public Health Agency of Canada, is that poor data quality and a lack of data showing preventative treatment measures means that nobody fully knows the extent of the outbreak.

TB monitoring failures

I sent ATI requests to the Nunavut Department of Health, Health Canada and PHAC asking how many people in Nunavut were offered prophylactic treatment after being exposed to TB, how many received it and how many completed it.

Ron Wassink, a communications specialist for the Nunavut Department of Health, said that no statistics for prophylactic treatment are available because “the database is still under development and as such is not ready to create summary statistics nor would it be appropriate to do so at this time until the database is fully operational.”

Prophylactic treatment can prevent people from developing latent TB, the not-yet-contagious precursor to active TB. Knowing the number of people offered prophylactic treatment, a treatment that is recommended by the World Health Organization but is not mandatory, gives researchers a true grasp of the amount of disease circulating in a community.

The data that do exist about the outbreak, as shown in the PHAC report I accessed, are frighteningly incomplete.

The report explains that each community in Nunavut should have been keeping a separate Excel spreadsheet for active cases and contacts and importing them into a database. However, some Nunavut communities were left out of this process because their records were “in a format not conducive for data import.”

Even now, in 2018, there is no adequate database for TB monitoring.

Incidence rates out of control

Each active case of TB requires contact investigation. This helps health officials find people who are at risk of developing and spreading the disease.

Contacts, which include people living in the same house, should be offered prophylactic treatment if they qualify for it, or they should receive follow-up monitoring for two years to check for symptoms.

The report shows that local health care workers failed to list the contact type in 42.4 per cent of investigations. This is assigned based on how much time the patient spent with their family member, spouse or perhaps a friend staying in their home.

The categorization of contact type is vital for determining whether a person should be treated.

While the federal government’s funding announcement and strategy are important steps in the right direction, the PHAC report shows that the current data are of poor quality and that the incidence rate of TB in Nunavut’s most vulnerable population is out of control.

With the hiring of more staff, a more culturally sensitive program and better quality data, it is entirely likely that the number of cases of TB detected will actually increase before they decrease because of better detection.

The ConversationUntil we can accurately quantify the scope of the current problem, it is very difficult to foresee an end to the current TB outbreak.

Sarah Giles is a Fellow in Global Journalism, Munk School of Global Affairs, University of Toronto and Voluntary Lecturer in Family Medicine, University of Ottawa

Disclosure statement: Sarah Giles does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

This article was originally published on The Conversation. Read the original article.

  Investigation of Tuberculosis Outbreak in Nunavut, 2017 by NunatsiaqNews on Scribd

 

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(10) Comments:

#1. Posted by Northern Guy on April 09, 2018

Why does the GN Department of Health continue to ignore basic principles of epidemiological control and assessment when it comes to tracking and monitoring highly communicable and potentially fatal diseases like TB? There seems to be a mindset that treatment and screening will do the job ... wrong!

#2. Posted by Looking for info on April 09, 2018

I seem to remember that there is a vaccine to protect against TB is there a reason why it is no longer administered in regions where there TB is rampant

#3. Posted by Luktaap Nulianga on April 10, 2018

Gee Dr Giles, I sure hope you do a better job of ‘evidence based’ medicine in your medical practice than you did with ‘evidence based’ journalism in this ill informed hack editorial.  Next time, before you write the prescription, try to talk to front-line health care workers, and not just some government flack, to make sure that you have a solid grasp of the facts.

#4. Posted by Holding some info on April 10, 2018

@#2 It’s called BCG and it’s available in Nunavut communities. It’s not 100% effective but way better than nothing.

#5. Posted by Mario Contrario on April 10, 2018

@#3 Because the front-line workers have developed their own contact investigation database without telling the government flacks? And they secretly made it consistent across health centres so that the data can be analyzed by… government flacks (or journalist hacks)?

I do like the way you rhymed “hack” and “flack”. You could have worked in “crack” or “smack”, although maybe “facts” at the end is an imperfect rhyme. Throw in some beatbox and you’re in business!

#6. Posted by Jim Bell on April 10, 2018

This is for “the doctor’s wife” or “Luuktaq Nulianga,” who made comment #3.

I don’t normally do this, but when somebody makes such a vindictive, narrow-minded remark about a highly-accomplished member of their profession, it deserves a response from this newspaper.

1. The commentary by Sarah Giles is not only based on solid reliable evidence, but evidence that is actually embedded into the body of the story. It’s available to you and to any reader. Read it and be enlightened.

If you scroll to the chart on page 9 of the Public Health Agency of Canada report at the bottom of the article, you will see that the 2017 rate of TB infection for infants under one year is 1,020.4 per 100,000. As the headline states, that’s more than one in 100.  This is not an opinion. This is the indisputable, objective fact that the evidence represents. The evidence revealing the sorry state of Nunavut’s TB contact database is also indisputable and speaks for itself.

2. The article contains multiple hypertext links to multiple studies on TB that also represent indisputable facts.

3. There’s a good reason why only “a government flack” is quoted in the story. The GN’s health department does not allow reporters to interview any staff members unless a government minder sits in on the interview. This has been their practice for years. It means, of course, that on those rare occasions when GN health staff are allowed to give interviews, they are inhibited from speaking freely. And most of the time, the “government flack” is the only person you can get a statement from.

This repressive practice is normally found only in authoritarian or totalitarian dictatorships—but that’s how the GN operates. The last paragraph of this fine article by Ann Silversides is particularly instructive.

https://maisonneuve.org/article/2014/08/20/nunavuts-nursing-crisis/

Last, if you think you have better evidence that would lead to a different conclusion, feel free to send us your opinion.

In any case, the evidence quoted in this article suggests that the GN does not have the capacity to handle this crisis on its own. It’s clear that the federal government, which has a constitutional obligation to provide health care to Indigenous peoples, must step in, and together with Inuit Tapiriit Kanatami, manage the elimination of this disease.

#7. Posted by Arnaujaq on April 10, 2018

Luuktaap Nulianga means the doctor’s wife.

#8. Posted by Jim Bell on April 10, 2018

Thanks for the correction. smile

#9. Posted by Luktaap Nulianga on April 10, 2018

@#5 and #6 /Mario amd Jim

I have re-read the article and your points. You do make several good points. In particular, it is indeed, unfortunate,  that jourmalists and the public are unable to get a more nuanced picture of our health care system, with all of its positives and negatives. I was reacting to the overall impressson the article left me with: that the healthcare sytem (at all levels) and frontline providers do not recognize the seriousness of the epidemic and are not, therefore,  doing their utmost to resolve it. However, I agree that I was unfair in my hasty assessment of the article.

Please remove my comment or at least post this addendum.

#10. Posted by Mario Contrario on April 10, 2018

@#9 Thank you for your follow up. My comment might have been excessively sarcastic - nothing personal.

I believe front line providers do, generally recognize the seriousness of the epidemic, and there is probably value in hearing them out. But there is also value in just doing a dispassionate review of what data is available and what isn’t. Sometimes I think we put too much stock in anecdote here in Nunavut.

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